LCAT

1. LPL LPL LPL HL HL CETP Oxidation CD36 SR-A Macrophage Recycling Arterial Wall NascentHDL ABCA1 LCAT LCAT The role of Phase I in the quest for “good”cholesterol- failure of the CETP modulator dalcetrapibJoint Conference 2013 of CPI | AGAH | BAPU | AHPPINice, 11 April 2013, Michael Derks

2. Outline Presentation • MOA of CETPi: Roles of CETP Inhibition in Atherosclerosis and HDL-C in CV risk reduction • Background of dalcetrapib • Clinical Pharmacology program: • SAD/MAD • DDI • Formulation; Food effect; • ADME • TQT • Special populations • M&S • Lessons Learned

3. N Engl J Med 2012; 367:2089-2099 • no association between HDL cholesterol levels and cardiovascular risk – no effect under optimal standard of care? • altered physiologic functions of HDLs, including reverse cholesterol transport? • mean increase of 0.6 mm Hg in systolic blood pressure • 18% increase in the median CRP • HDL too low / LDL not decreased?

4. N Engl J Med 2012; 367:2089-2099 • no association between HDL cholesterol levels and cardiovascular risk – no effect under optimal standard of care? • altered physiologic functions of HDLs, including reverse cholesterol transport • mean increase of 0.6 mm Hg in systolic blood pressure • 18% increase in the median CRP • HDL too low / LDL not decreased

5. Phase III and Submission Failures: 2007 – 2010combined success rate at Phase III and submission ~50% • Novel mechanisms of action in areas of high unmet medical need • Progression into Phase III trials with limited proof of efficacy in Phase II POC • Assumption that success in one disease will translate into success in a different disease Nature Reviews Drug Discovery 10, 87 (February 2011)

6. HDL-C Predicts Risk for CAD Independent of LDL-CFramingham Heart Study • HDL-C is inversely correlated with CAD risk • Correlation is independent of LDL-C 3 2 CAD Risk After 4 Yearsa 1 25 (0.7) 45 (1.2) 65 (1.7) HDL-C, mg/dL (mmol/L) 0 85 (2.2) 100 (2.6) 160 (4.1) 220 (5.7) LDL-C, mg/dL (mmol/L) aMen aged 50–70 Castelli. Can J Cardiol. 1988;4(suppl A):5A–10A.

7. Benefits of Raising HDL-C Barter. Eur Heart J Suppl. 2004;6(suppl A):A19-A22 Barter. ArteriosclerThrombVasc Biol.2005;25(7):1305-1306 Animal Studies Raising HDL-C either by infusing HDL-C or by increasing the synthesis of apo-A1 by genetic manipulation greatly inhibits the development of atherosclerosis in both mice and rabbits Human Studies Raising HDL-C by treatment with either niacin or fibrates in intervention trials is associated with a slowing of progression of CHD and a reduction in CV events Infusion of reconstituted HDL-C reduces the atherosclerosis burden as assessed by IVUS

8. ILLUMINATE Trial: Higher Achieved HDL-C in Torcetrapib Treated Patients, Lower Event Ratea Hazard Ratios for CHD Death or Non-fatal MI by Quintile of On-Trial HDL-C (Referent Group Is HDL-C <60 mg/dL [1.55 mmol/L] Stratum) P<.05 vs HDL-C <60 (<1.6) CHD Death or Non-fatal MI (Hazard Ratio) Quintiles of HDL-C, mg/dL (mmol/L) at Month 3 aCox proportional hazard model adjusted for age, gender, and baseline HDL-C. Excludes 265 patients with missing month 3 HDL-C values. Barter et al. Presented at: American Heart Association Scientific Sessions. Nov 4-7, 2007; Orlando, Florida

9. Human CETP deficiency is associated with marked increase in HDL-C1 CETP activity is inversely correlated with plasma HDL-C1 Reduction in CETP activity is associated with a marked reduction in the cholesterol burden in TG-rich particles in both fasting and postprandial phases2,3 Decreasing CETP activity has consistently inhibited atherosclerosis in animal models1 Role of CETP Inhibition in Atherosclerosis LDL VLDL Atherosclerosis CE LDL-R LDL CETP FoamCells TG ABC-A1 Free cholesterol HDL Bile RCT ABC-G1 Liver Plasma Peripheral tissue 1Barter et al. Arterioscler Thromb Vasc Biol. 2003;23:160–167; 2Contacos et al. Atherosclerosis. 1998;141:87–98; 3Guerin et al. Arterioscler Thromb Vasc Biol. 2008;28:148–154.

10. Background of dalcetrapib • Dalcetrapib is a cholesteryl ester transfer protein (CETP) inhibitor • Discovered by Japan Tobacco who performed initial Entry in Man and Ph2a studies • Roche took over clinical development in beginning in 2005 • By 2010 extensive program of clinical studies had been developed • 33 completed healthy volunteer studies and 10 completed Phase 2a patient studies

11. Dalcetrapib CETP3 Cys13 Dalcetrapib1 Dalcetrapib binding site Cholesterylesters Molecular weight: 389.60Lipophilicity: cLogP ~7 Phospholipids • The cysteine at residue 13 of CETP seems to be essential fordecreased CETP activity with dalcetrapib2 • Dalcetrapib binding to CETP appears to induce a conformational change in the CETP molecule2 Prodrug and highly lipophylic in vitro DMPK experiments of limited value Primary route of metabolism through glucuronidation and methylation PK concentration based on derivitizationof circulating thiol 1http://www.ama-assn.org/ama1/pub/upload/mm/365/dalcetrapib.doc;2Okamoto et al. Nature. 2000;406:203–207; 3Qiu et al. Nat Struct Mol Biol. 2007;14:106–112.

12. Clinical Pharmacology contributes across the whole value chain • Dose justification for confirmatory studies and regulatory submission • Simulate confirmatory trials to assist in design optimisation • Optimise drug label • Investigate response variability and dose-adjustments to maximise efficacy and safety • Investigate/confirm mechanism of action • Confirm effects on important safety issues (eg QTc) • NDA/MAA and regulatory questions • Disease models for target identification and validation • Design first in man studies • CTA/IND • Define dose-exposure-effect for pharmacology and tolerability • Identify significant causes of PK/PD variability • Confirm dose for PoC study • Simulate PoC (and other) studies to assist in design optimisation • Characterise significant “developability” questions • Paediatric investigation plan • Assess molecule for “drugability” • Identify suitable biomarkers • Create phase I plan • Bridging strategies for new populations and formulations • Line extensions • New indications

13. Basic pharmacokinetic or pharmacodynamic studies • SAD and MAD studies in healthy volunteers • SAD (JT, MAD (JT), MAD (JT), MAD, SAD/MAD • Single doses up to 4500 mg, short-term repeated dosing up to 3900 mg/day; moderately variable PK; approximately dose linear • Mass balance study • Extensive and complex metabolism, no human-specific metabolites identified • Thorough QT study • No clinically relevant effect on QT interval duration • Special population studies • Exposure modestly higher in moderate and severe renal impairment • No effect of moderate hepatic impairment

14. Dalcetrapib Phase IIadose ranging

15. Biopharmaceutics study • Food effect and food timing studies (3X) • ~2-fold higher in exposure fed vs. fasted state • Size of food effect depends on size and fat content of the meal • Rel. bio./bioequivalence studies (4X) • Bioequivalence linkage between JT and Roche tablet formulations • Exposure inversely related to particle size • 2nd generation formulation studies (4X) • Modified release formulations • Nanoparticle capsule • Nanoparticle suspension

16. Drug-drug interaction studies • Statins • Atorvastatin x 2, simvastatin, pravastatin, rosuvastatin • Dalcetrapib exposure reduced in combination with statin, extent dependent on size of LDL change (e.g. 8% with pravastatin, 35% with rosuvastatin) • No apparent effect on CETP inhibition or HDL effects of dalcetrapib • No clinically relevant effect on statin exposure • Cholesterol absorption inhibitor (ezetimibe) • No clinically relevant interaction • Thiazolinedione (rosiglitazone) • No clinically relevant interaction • Lipase inhibitor (orlistat) • Dalcetrapib exposure markedly reduced by clinical doses of orlistat

17. Drug-drug interaction studies (cont.) • CYP3A4 inhibitor (ketoconazole) • No clinically relevant effect on dalcetrapib pharmacokinetics • ‘Cooperstown+1’ cocktail • No clinically relevant effect of dalcetrapib on cytochrome P450 activity • Narrow therapeutic window (digoxin) • No clinically relevant interaction • Oral contraceptives (Microgynon) • No clinically relevant interaction

18. Relationship between dalcetrapib plasma concentrations and LDL-C levels

19. 60 50 40 *** 30 *** ** *** 20 10 Change from baseline (%) 0 -10 * *** *** -20 * *** *** -30 -40 *** -50 Total cholesterol HDL-C LDL-C Triglyceride ApoA-I Changes in plasma lipids in 22 dalcetrapib-treated subjects with or without ezetimibe dalcetrapib 3x300 mg ezetimibe 10 mg dalcetrapib 3x300 mg + ezetimibe 10 mg Niesor EJ, et al. Atherosclerosis. 2011;219:761-767 Mean ± SEM; n = 22. *P < 0.05, **P < 0.01, ***P < 0.001

20. CETP has multiple activities: transfer of cholesteryl ester between HDL3 and HDL2, LDL and VLDL HDL2 HDL3 VLDL LDL Liu XQ, Bagdade JD. J Lipid Res. 1995;36:2574-2579

21. CETP inhibitors vs. CETP ModulatorsChanges in conformation of CETP will modulate activity INHIBITORS MODULATOR anacetrapib torcetrapib • Dalcetrapib binds in the tunnel of CETP inducing a fixed conformational change • This change in ‘shape’ means it is unable to interact with lipoproteins of large diameter such as LDL and VLDL • CETP is still able to transfer cholesterol between HDL sub particles • Inhibitor binds to CETP and HDL forming a triple complex • CETP does not dissociate efficienly from any lipoprotein and CETP activity is fully inhibited Atherosclerosis. Dec;219(2):761-7. Niesor et al

22. Genetically raised plasma HDL cholesterol is not associated with risk of myocardial infarction. Some ways of raising HDL cholesterol might not reduce risk of myocardial infarction in human beings.

23. What else could have been done • Quantitative assessment of drug distribution into lipid subfractions following oral dosing in a clinical study • Quantitative drug distribution into different lipid fractions in vivo has not been established; hypothesised that changes in lipid profiles (e.g. in response to food, renal impairment, with lipid-modifying con meds) will change distribution, ‘free fraction’ and clearance • Pharmacokinetic modeling of existing active form and metabolite data from preclinical and clinical studies • Hepatic extraction of thiol changes over dosing interval; possibility of metabolite inhibition of thiol metabolism (i.e. auto-inhibition) • A clinical study to characterize effects on postprandial lipaemia • No clinical data on the acute effect on postprandial lipid profiles; clinical data available on torcetrapib, niacin, fibrates, statins • A clinical relative bioavailability study employing an oral solution formulation • Absolute bioavailability unknown and influence of dissolution on absorption not understood; an IV formulation is technically unfeasible

24. What else could have been done • A preclinical study to investigate lymphatic transport using a cannulated animal model • Contribution of lymphatic transport in absorption phase is unknown • Additional GastroPlus modeling of drug absorption using existing data • Absorption processes not understood; molecular species absorbed after oral dosing is unknown (thioester? thiol?) • A clinical study to compare the pharmacodynamic effects of different dosing regimens • Applicability of empirical PK/PD model to different clinical dosing regimens not proven; unproven which exposure parameter best predicts pharmacological response • Measure faecal sterol excretion in clinical study • Effects on reverse cholesterol transport in humans have not been proven

25. Lessons learned • Even good science does not make a compound work • Most markers are not surrogate and almost none are validated – nevertheless, sometimes it may be worth to take the risk to run large Phase III studies; would RCT / Entelos / genetic studies etc have stopped the development of dalcetrapib? Should a PoC in higher risk patients have been done? • Compounds with unfavourablephysico-chemical properties should be deslectedpreclinically, but that does not mean they cannot be developed successfully • Dose selection should start to be addressed as early as possible (prior to PoC) and popPK should be done in Phase II (and III) • Formulation optimization should be done in a strategic way • Small signals should be explored as they can lead to useful insights • Continuously learn from competitors • Big projects with high (time) pressure: consult with Clin Pharm colleagues often and reevaluate the strategy so that opportunities or risks are not missed

26. Doing now what patients need next